A Doctor's Quest: Teaching brain surgery in the bush

A man lies in a hospital deep in the Tanzanian bush, dying of a head wound. His only chance is if someone opens his skull and stops the bleeding, but the hospital doesn't have a bone-cutting saw. An American brain surgeon volunteering at the hospital has an idea: A villager next to the air strip is cutting a tree limb with a wire saw. That might do. He buys the wire saw for $15 and heads back to the operating room. Improvise. That's what you do when you're a doctor in one of the poorest countries on earth. This is the story of a brain surgeon from Charleston and his mission to teach Tanzanians his skills.

Open the skull, and look at the brain. It's beige with a slight tint of pink and shaped vaguely like the head of a cauliflower. Now touch it. That's what Dr. Dilan Ellegala asks his medical students to do. Feels like thick porridge, the ones in Tanzania tell him. Feels rougher around the blood vessels, the students in South Carolina say. Ellegala knows that if he or one of his students cuts the wrong blood vessel, the brain will begin to die. They have just a few seconds to save it. If they fail, their patient may lose the memory of a child, or ability to taste or walk or breathe. No, Ellegala doesn't say anything about the stakes when his medical students touch those moist folds; he wants them to suspend their fears, expand the capacity of what they think they can do, feel the wonder and privilege of getting inside another human being's head.

God complex? Neurosurgeons hear it all the time. And truth be told, if you spent 14 years in medical school for this, spent day after day doing life-and-death surgeries, been told over and over that your medical specialty is among the most difficult, lucrative and mysterious, wouldn't your brain swell a little, too? Yes, arrogance comes with the territory, though when you dig a little deeper, you'll find that many neurosurgeons wrestle with insecurity and that they went into this odd profession to beat it back, prove something to themselves, Ellegala included. "Audacity, more audacity, always audacity," he says one afternoon while flying over the green rainy-season plains of Tanzania, citing Gen. George Patton, whom he admires for living a pure life despite his flaws.

Ellegala knows his dreams are audacious, but he can already see them playing out in Tanzania amid the blistering heat and smell of wood smoke. He can see their growing imprint on the Medical University of South Carolina, where he also practices and teaches. But why stop there? He can see how his work could help create a new model for health care in the

developing world, a model that may save countless lives, an idea that could restore some dignity to Tanzania, the place where it all began, where pre-humans first walked upright, triggering an expansion in the cranium that enabled man to make hammers, spears and, much later, MRIs and other tools that would unlock the brain's delicate and audacious machinery. Yes, Africa is where it will work, he thinks, the place where he found a sense of peace, where he camped with tribesmen who talk to birds, brainstormed with Tanzania's president about stopping the cycle of dependency on foreign doctors, where he met his wife. It will work, he's convinced, and you can see the fire in his eyes, the focus. He's a brain surgeon, after all, and if he's not right, people can die.

January 2006

Sala begins at 8 a.m. sharp every morning at Haydom Lutheran Hospital, a medical center for about 2 million people south of the Serengeti. Sala is part church service, part staff meeting. A choir sings in Swahili as hospital workers filter into the circular chapel, sunlight streaming through the tall narrow windows. A member of the staff gives a sermon in Swahili and English, and Dr. Oystein Olsen, a cheerful Norwegian whose father founded the hospital, makes announcements and introduces or says goodbye to visitors, usually doctors and medical students from Europe and the United States. In January 2006, Olsen introduces a neurosurgeon from America, Dilan Ellegala, and asks him to step to the front and tell the staff about himself.

Ellegala stands near the lecturn. He's about 6-foot 2, with skin the color of caramel. He has a prominent nose and large eyes framed by arching black eyebrows that give his face the focused look of an eagle. He keeps his head shaved and points to it often when describing an operation, a perfect aid for teaching neurosurgery. He tells everyone in the chapel he's happy to be in Haydom; he doesn't mention the real reason, though, that he's here to recover.

It takes time to build an American neurosurgeon: Four years of medical school and eight years of residency, and even more time if you want to be a cowboy -- a neurosurgeon who specializes in vascular work. Vascular neurosurgeons treat dysfunctions of the blood vessels, such as aneurysms, those tiny time bombs in the brain that can rupture in a blink and cover everything with blood and give you just a few seconds to figure out what to do before the patient loses a memory, is paralyzed or dies.

But it takes more than training to become a brain surgeon, so let's go deeper, to Sri Lanka in 1969 where Ellegala is born, where his parents are high school teachers and uncles are doctors, where his father decides that they have a good life in Sri Lanka but will have a better one in America if they work hard enough. Ellegala is 5 when his parents move to South Dakota of all places, as cold as Sri Lanka is hot. In the 1950s, his father studied at South Dakota State under a Fulbright Scholarship, and after all these years, the elder Ellegala still has friends there. The town, in fact, welcomes the Ellegalas back with a front-page story in the local paper. They have friends but little else; stuffed in his father's shirt pocket is the only money the family has, a $20 bill.

His father gets a job at the local Pizza King, and the five of them, counting his two sisters, move into a tiny apartment above the restaurant. A Sri Lankan in South Dakota can raise eyebrows, and at school, four of Ellegala's classmates call him "nigger." His father tells him to let it go but also teaches him how to box. Ellegala methodically finds each bully and punches him out, and as will happen when you're a young boy, the fights melt the ice, and the bullies end up being his best friends. A spark hits tinder somewhere here, and Ellegala realizes that risk has its rewards, that you can change your condition with a little work. He has plenty of other examples. The family eventually moves to the Seattle area, and he sees how his father delivers newspapers in the morning, works with disabled people during the day and washes dishes at a hotel at night. He watches his mother go to bookkeeping classes. He sees his parents' sacrifices, hears the fatigue in their voices at the end of the day, feels their devotion to their children's futures. Will he be worthy of them?

His report cards in grade school ask: What do you want to be when you grow up? "Doctor," he scribbles year after year. He tells everyone he'll be a doctor someday; who wouldn't be proud of him then? He breezes through high school with stellar grades, and then college. During his third year of medical school at the University of Washington, the chief surgeon hands him a scalpel and tells him to cut a patient's artery.

What, he thinks, Can I really cut open a human being, fix something inside and put it all back together? I'm just a med student. The chief surgeon looks him in the eye and says, "Anything you mess up I can fix." That nudge is enough; he'll show everyone he can do this, show himself, just as he showed those young boys in South Dakota, just as his parents showed they could build better lives. He finishes the surgery without any help. Now he's hooked on the adrenaline, gaining more confidence, doing more complex surgeries, till the brain, the Everest of the body, is all that's left to conquer, the seat of the soul.

He enters the high-pressure neurosurgery program at the University of Virginia, with a track record of producing the most department heads in the country, reputation for accepting residents who want to be leaders and not-so-gently pushing out those who lack this ambition. At Virginia, Ellegala develops new ways to measure blood flow in the brain, authors or co-authors dozens of papers. Finally, after 13 years of medical school and residency, he is awarded a cerebrovascular fellowship at Brigham and Women's Hospital at Harvard, at the time among the most rigorous programs of its kind in the nation.

More adrenaline. He loves the new jolts as he works with aneurysms, disarming those time bombs. He relishes the challenges from his teachers to be perfect because anything less could be a disaster. But he hates the sleepless nights. At one point, he realizes that he spends an average of 2 1/2 hours a day at home, including sleep time. He goes without sleep for two or three days at a time, scrubbing up for one surgery after another, fielding rapid-fire questions from brusque teachers who reduce some of his peers to tears. It's Navy SEALS training, Special Ops for docs. If you survive, you're an elite among elite. But he knows this pace does something to a person's brain. Sure, it hardwires it to do some the most complex and dangerous surgical procedures in medicine, but it also grinds body and soul into hamburger. He sees people in his specialty marry, divorce, remarry and have affairs. So before he begins the Harvard fellowship, he promises himself that he will take a year off when he's done and find what part of himself he may have lost.

He survives the fellowship and keeps that promise; he'll go on a medical mission, get a little traveling in and keep his medical skills sharp. But where? His girlfriend plans to work at Haydom Lutheran Hospital in central Tanzania. Haydom? Why not? Strange place for a vacation, though. Norwegian missionaries founded Haydom in 1953 on a mile-high plateau near a mountain piled high with 50-foot-tall boulders that look like giant potatoes. Farther in the distance was Mount Hanang, fourth-tallest in Tanzania and often shrouded in clouds. In another direction was the Rift Valley, birthplace of humanity, with elephants and hyenas, home to the Hadza, people who speak with tongue clicks, hunt for food as our ancestors did before the Stone Age. The hospital's first patients? Four men attacked by leopards.

When Ellegala lands in Haydom in January 2006, he's 36 years old and finally done with his training, a fully credentialed neurosurgeon. Red swirls of dust fill the valley. He fills his lungs with the scents of wood smoke, sweat and dirt, and the spell is cast. He sees the acacia trees in the distance, hanging like a green fog off the plains, the fields of sunflowers and maize, the Datoga herding their cattle, tall and rail-thin people with circular tattoos around the eyes and clothed in wraps the color of the red-clay soil. He wanders outside the gates and eats chips mayai -- French fried potatoes and beaten eggs sizzling in a frying pan. The hospital has created its own gravity over the years, drawing 20,000 people, huts and shacks around its gates, a village that today remains missing on many maps. It's raw and dusty and beautiful, and he hasn't felt so alive in a long time.

*

After Sala, the doctors meet in a small radiology room to go over the day's cases. The room is set up like a classroom with chairs facing a light board for X-rays and images

from a new CT-scanner. On his first day, Ellegala realizes that several patients need neurosurgery soon or they'll die. Rains were scarce in 2004 and 2005, and now the children's ward is filled with children dying of malnutrition. He's ready to get to work, but he'll need to improvise; the hospital can handle basic surgeries, not neurosurgery. No time to waste, no pleas to equipment makers to donate what he needs; he'll use a camping headlamp to peer into these damaged brains and duct tape to hold tools in place; he'll cut apart stainless steel scraps in the hospital's garage to fuse spines, use sutures without needles.

He sees a child with hydrocephalus, a buildup of fluid that can make a person's skull double in size. If caught in time, it's easily drained with a shunt, but the hospital doesn't have any. Ellegala cuts up a plastic IV tube and uses the pieces as shunts. He sees another patient with severe bleeding inside the brain. The man is in his fifties and fell on his head after a drinking bout. He needs a craniotomy, a surgical operation to remove a portion of the skull, and without it, he'll die in 12 to 24 hours. But Ellegala needs a special tool to cut the bone, and the hospital's ancient bone-cutting saw is rusty and broken.

He takes a walk in the late afternoon to the airstrip to clear his head. Out of the corner of his eye, he notices a tree shaking and two arms pumping back and forth. Memories flash through the doctor's mind: photos of gear in an REI catalog, days spent canoeing in the Northwest woods. It's someone using a wire saw, he thinks. That might just work.

"Jambo," Ellegala says in Swahili he has been trying hard to learn, hello. The man is in his 50s and has a brightly colored wrap draped over his shoulders. Ellegala gestures to the man's wire saw.

"Can I buy this?" Ellegala asks.

The man looks back at him, amused. Why would this American want his saw?

Ellegala can only point to that simple saw and say in broken Swahili: "I want to use it in the hospital." He pays the equivalent of $15 in Tanzanian shillings and heads back to the hospital.

He sterilizes the saw with steam and dons his scrubs. He drills two holes into the patient's skull with a medical hand drill and inserts one end of wire saw. He draws it through to the other hole and begins to cut the bone. When the brain is exposed, he stops the bleeding and reattaches the skull.

After he's done, word spreads through the hospital. "We have a neurosurgeon!"

*

During his first week in Haydom, Ellegala notices that the foreign medical students and doctors sit in the front during the morning X-ray meetings, and the Tanzanians sit quietly in the back. Most of the overseas doctors are here for a few weeks or months, but they control the meetings, fluidly demonstrating their knowledge and experience. He knows he'll be leaving in a few months, just like the other foreign doctors. He thinks, sure he and his fellow Western doctors have come here to help people. They've saved lives. But what happens when we leave? When we're gone, who will do the shunts, the craniotomies? Not the Tanzanians. The country is so poor that it has one of the worst doctor-patient ratios in the world. He's one of more than 3,500 brain surgeons in the United States. Tanzania has three.

Ellegala takes notice of a man named Emmanuel Mayegga, who is not a doctor but has several years of clinical training under his belt. Other Tanzanians at the hospital seem to look up to him. Ellegala sees something else, something intangible that he's noticed in fellow surgeons, a swagger maybe, something in the way he carries himself.

After a morning meeting, Ellegala talks to Naftal Naaman, a radiologist, former mayor of Haydom and wise man of the hospital. Tanzanians should be doing these procedures, Ellegala says. "Let's train someone, like Mayegga. What do you think?"

"I'll teach you, otherwise when I go, you won't have anyone. Think about it."

*

Ellegala knows Mayegga will become a surgeon only if he changes the architecture inside his brain, creates a new door that he can boldly walk through to a place he never dreamed he would be. And he needs a teacher to nudge him through that door, just like that chief surgeon who handed Ellegala the scalpel in medical school. But will Mayegga respond?

Sure he will, Ellegala thinks. As he gets to know his student, he'll learn how he was born so poor that his parents didn't keep track of his birthday, that Mayegga grew up in a hut of sticks and mud and as a boy chased monkeys from the family's small maize plot and was hunted by a python across a rocky hill, that he helped his family plug holes in the hut's roof with animal skins when it rained, that he sold charcoal to buy his school uniform and woke up at 5 a.m. and ran on narrow bush roads for two hours to get to school in time.

Ellegala takes Mayegga into the operating room, and as he does with all of his students, asks him to touch the brain.

"It was really astonishing to me," Mayegga recalls later. "I was thinking it was like porridge. It was pulsating and very soft."

But Ellegala senses Mayegga's anxiety and wonders, Can he really do this? Sure, remember what Mayegga already has done, how as a child he helped his family during droughts by taking blood from the veins of cows and cooking it in a pot to eat; how as a teen, he studied by a kerosene lamp late into the night and woke up slumped next to it, his nostrils full of its soot; how as a young man, he studied three years to be a "clinical officer," the American equivalent of a paramedic, and later studied to be an assistant medical officer, roughly akin to a physician's assistant.

Ellegala sees how good Mayegga is with a scalpel, but after a hard day of training, Mayegga sometimes shows up at his door at night with alcohol on his breath and questions about whether a non-MD should really be doing this kind of surgery. Is he cracking? Ellegala needs to work more on Mayegga's mind, help him believe in himself. He comes up with a ruse:

In medicine, whether you're in Tanzania or America, there is a long-established pecking order. The top doctor directs questions to the junior medical students first, and then moves up the ladder if they don't have the correct responses. The day before a training session, Ellegala tells Mayegga the questions he will ask and the answers. The next day, Ellegala fires off his questions, starting with the Western medical students and moving on when they come up empty. He turns to Mayegga, who answers with ease. They look at him, seeing perhaps for the first time, a Tanzanian who sounds like them.

Then one afternoon, Ellegala and Mayegga are in the operating room together, but this time Mayegga is the lead surgeon. Mayegga will put in a shunt, a relatively simple procedure but still brain surgery. It's a big day at Haydom Lutheran Hospital. Nurses and other members of the hospital staff gather around the operating table, about 10 people, and Mayegga does the procedure flawlessly, and everyone in the room smiles and shake hands. Ellegala steps away and claps his hands loudly for effect and shouts: "You've got yourself a neurosurgeon now! I'm leaving!"

June 2006

Another dry season begins, and Ellegala's mission in Haydom is over. His relationship with his girlfriend has evaporated amid the heat of his desire to train Mayegga and others at the hospital. He's convinced that the dependence on foreign doctors has become a tumor, crowding out the healthy growth of Tanzania's health care system. He walks up the dusty red-clay road to the airstrip, the place where he found the man with the wire saw. A few villagers stand silently as the bush plane lands on the grass and taxis toward him and his luggage. He climbs in, the plane rumbles down the strip, passing the sunflower fields, the villagers as still as statues, and he feels as if he's leaving a piece of himself behind.

The series

TODAY: Dr. Dilan Ellegala, a Charleston neurosurgeon, does brain surgery in the African bush, then decides to teach others there how to do it.MONDAY: Do short-term medical missions make sense? Ellegala says no while facing an uncertain future.TUESDAY: Ellegala creates a nonprofit to teach brain surgery in Africa, and finds love in the process.WEDNESDAY: Ellegala and MUSC team up to create an international model for health care training in developing countries.

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